7/1 Bob AMPS=342, +5=286 Acupunture and Chromium??

I would say "happy Monday", but it's a quite dreary, depressing Monday over here. I took Bob to the specialist for his exam. Here are the highlights:

1. he's gained a little weight (which she says is better than losing right now although he shouldn't gain too much more)
2. she lectured me for increasing his insulin without consulting her. she had him on 2.5 units a few weeks back and wanted me to leave him on that
3. she tested his blood for ketones and she said he has SLIGHT ketones. she said she had to get three other people to confirm because it was such a small amount.
4. she took a fructosemine test and will get the results in a few days. she wants me to keep him on 3.5 until she talks to me.

Well, needless to say, I am absolutely petrified about the ketones - I'm not surprised because Bob's numbers are so high. What should I do and what should I watch for??????

I'm so upset.....

Re: 7/1 Bob AMPS=342, +5=286 We have ketones??

Monitor dehydration, for one thing.

Moderate-major dehydration check: pull up scruff and release. If it stays pulled up - "tented" - there is moderate to major dehydration
Minor dehydration or more - press finger firmly on gums. release. does it pink right back up or does it stay blanched? The latter indicates some dehydration.
Urine output - none (not good - could be blocked), tablespoons, cups, pints, lakes of mud? Quantity? About 1/2 cup per day is an average I've seen.

Edited to add: The concentration of glucose or ketones in the urine or blood will be increased with dehydration; conversely, may be decreased with adequate hydration. Also, dehydration occurs with a variety of problems, so it can be helpful to rule OUT or rule IN some conditions. That's the reason you check for it when assessing your cat's overall health. Its right up there with eating and pooping, drinking and peeing, and so on.

Re: 7/1 Bob AMPS=342, +5=286 We have ketones??

I'm sorry,sending healing vines out to you

Re: 7/1 Bob AMPS=342, +5=286 We have ketones??

First, trace ketones can be dealt with at home. Get a ketone test whenever you can. Did the vet check urinary or blood ketones? If the former, it's particularly important for you to test. It takes several hours for waste products (i.e., urine) to collect and for the cat to excrete the urine. As a result, the ketone level isn't to the minute. It could be that the ketone levels have come down or have gone up. Blood ketones are more immediate.

First, remember this is YOUR cat. The vet works for you. You are Bob's voice. Do not let the vet intimidate or chastise you. If you know any human diabetics, they change their insulin dose based on their home glucometer readings. This is standard practice. You are following a dosing protocol that has evidence based research to support it. I can send you the journal article to share with the vet if you want it.

Dehydration isn't the issue since I'm presuming that if the vet thought Bob was dehydrated, she'd have given Bob subcutaneous fluids. Hydration is one way to address ketones. In other words, add fluid (water, sodium free chicken broth or tuna water that doesn't have any soy in it) to Bob's food -- as much as he can tolerate. The additional fluids help to "dilute" ketones.

Vets like fructosamine tests. IMHO, they are a waste of your money given that you have been home testing for well over 2 mos. The purpose of a fructosamine test is to tell you what the average of Bob's BG numbers have been for a 2 - 3 week period. Given your test data, you have much more accurate information. I'd ask the vet why your home testing data isn't more accurate. (She'll no doubt say something but the bottom line is you can decline the test and give her an average off of your spreadsheet. Usually, the vets don't want to take the time to look at a SS or run the averages themselves. I've had the same discussion with one of the vets where I take Gabby.) I would not base a decision to change an insulin dose based on an average that's going back 2 - 3 weeks. It doesn't make sense. FWIW, I've been managing Gabby's diabetes for 4 years. I do not contact my vet about her dose. They do not give me a second's worth of static about my adjusting her dose either. Unless your vet wants to be available to take your calls 24/7, lecturing you about changing Bob's dose is, IMHO, out of line. If she's that interested, give her the link to Bob's SS and she can check on him on a daily basis.

Personally, I'd suggest raising Bob's dose to 3.75u. The best way to fight ketones is more insulin.

Ketones occur due to several factors. The first factor is not enough insulin. Insufficient insulin + an infection or inflammation + not eating result in ketones developing. Also, BG numbers don't have to be sky high for ketones to develop.

I would want to be certain that Bob doesn't have any infection brewing. Urinary tract infections and dental issues are often the ones that can contribute to ketones, especially in a ketone-prone cat. Did the vet check for any infection or inflammation?

Re: 7/1 Bob AMPS=342, +5=286 We have ketones??

Sienne and Gabby said:

First, trace ketones can be dealt with at home. Get a ketone test whenever you can. Did the vet check urinary or blood ketones? If the former, it's particularly important for you to test. It takes several hours for waste products (i.e., urine) to collect and for the cat to excrete the urine. As a result, the ketone level isn't to the minute. It could be that the ketone levels have come down or have gone up. Blood ketones are more immediate.

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the ketones were in his blood. It's hard for me to test his urine at home. I am going to take Bob to his regular vet on Saturday for another one. She said it was such a small amount to not worry at this point.

Sienne and Gabby said:

Vets like fructosamine tests. IMHO, they are a waste of your money given that you have been home testing for well over 2 mos. The purpose of a fructosamine test is to tell you what the average of Bob's BG numbers have been for a 2 - 3 week period. Given your test data, you have much more accurate information. I'd ask the vet why your home testing data isn't more accurate. (She'll no doubt say something but the bottom line is you can decline the test and give her an average off of your spreadsheet. Usually, the vets don't want to take the time to look at a SS or run the averages themselves. I've had the same discussion with one of the vets where I take Gabby.) I would not base a decision to change an insulin dose based on an average that's going back 2 - 3 weeks. It doesn't make sense. FWIW, I've been managing Gabby's diabetes for 4 years. I do not contact my vet about her dose. They do not give me a second's worth of static about my adjusting her dose either. Unless your vet wants to be available to take your calls 24/7, lecturing you about changing Bob's dose is, IMHO, out of line. If she's that interested, give her the link to Bob's SS and she can check on him on a daily basis.

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This is very frustrating because I do like this vet (the specialist), she just doesn't agree with this protocol. I told her I was following the tight regulation protocol and she said "the one that Lantus put out?" - I don't know the answer to that! Anyway, she doesn't think it's a good idea to test constantly at home and nothing I can say will change her mind. She also likes to stay on the same dose for a week or two. I think I will just have to do my own thing. I just like having the regular contact with her because they have a great reputation and if Bob ever has to be hospitalized, I'd rather take them there than to his regular vet.

Sienne and Gabby said:

Personally, I'd suggest raising Bob's dose to 3.75u. The best way to fight ketones is more insulin.

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I will probably do this and just not tell them. Geez! I hate having to lie about stuff but they just don't agree. I think they think I'm pulling stuff off the internet randomly ad I've tried to explain the board and the AHAA stuff, but no good! ohmygod_smile

Sienne and Gabby said:

Dehydration isn't the issue since I'm presuming that if the vet thought Bob was dehydrated, she'd have given Bob subcutaneous fluids. Hydration is one way to address ketones. In other words, add fluid (water, sodium free chicken broth or tuna water that doesn't have any soy in it) to Bob's food -- as much as he can tolerate. The additional fluids help to "dilute" ketones.

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Bob is not dehydrated although I will give his extra fluids for if that will help. Is it ok just to give him some tuna water by itself? If so, how often?

Does anyone have any experience with acupuncture and supplements? My regular vet said it might be something to try and I spoke to the receptionist and her kitty was up to 10 units of Lantus (6 months after diagnosis) and she started him on acupuncture and supplements and he's down to 1 unit now. She said chromium is very popular, but you have to watch the BG at home really carefully, because if it works, it can cause it to go down pretty quickly. It's something to think about....I will research it myself of course....

Dara --

I would suggest dropping Marje a note. She uses a holistic vet and is more knowledgeable about supplements than I am.

Lantus never published a tight regulation protocol. In fact, Lantus does not have an indication for veterinary use so there's no way the manufacturer, Sanofi, would have a protocol. The Tight Regulation Protocol was published by a vet at University of Queensland (Jacqui Rand, DVM) and one of the members of the German Lantus board (Kirsten Roomp) who is a scientist. The protocol was published in one of the leading veterinary journals. I have no idea what the specialist you saw is referring to. I've attached the journal article. Usually, most vets will be a bit more open minded if you hand them an article from a journal they are familiar with.

In addition, the American Animal Hospital Association Guidelines for diabetes treatment of dogs and cats recommends home testing.

[url=http://www.felinediabetes.com/AAHADiabetesGuidelines.pdf:303twi57][b:303twi57]AAHA Diabetes Guidelines[/b][/url] said:

Cats
1. At-home monitoring is strongly encouraged, as results are more reliable.
2. On PZI: Measure BG every 2 hours until next dose of insulin.
3. On insulin glargine (Lantus): Measure BG prior to dose, 4 and 8 hours following insulin administration, and prior to next dose.

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So, basically the organization that accredits veterinary hospitals has recommended that you test at least 6 times per day. I somehow get the feeling that this vet may not be entirely appreciative of your hitting her over the head with the facts. You may need to handle this tactfully but the bottom line is you are doing the responsible thing to care for Bob. Of course, you don't need to tell the vet what you're doing. It's not like she's at home with you!

The problem with sticking with a dose that isn't bringing your cat into good numbers is that there is a risk of glucose toxicity developing. Basically, what this means is that the cat's body becomes accustomed to sitting in less than desirable numbers and treats these higher ranges as the new "normal." As a result, it's harder to get the numbers to come down and there is a greater likelihood of bouncing. This is why with Tight Regulation and even with the Start Low Go Slow approach, doses are evaluated anywhere from 3 - 7 days. Once a cat is in closer to normal range numbers, then staying at a dose for a longer time makes more sense.

Giving Bob tuna water all by itself is fine. I would just make sure that there's nothing in it except tuna and water -- no onions, garlic, soy, salt, etc. Most cats don't have a huge thirst drive. This is why adding liquid to our cat's food will often insure that they will get additional fluid. If Bob will slurp up tuna water, go for it.

Sienne and Gabby said:

So, basically the organization that accredits veterinary hospitals has recommended that you test at least 6 times per day. I somehow get the feeling that this vet may not be entirely appreciative of your hitting her over the head with the facts. You may need to handle this tactfully but the bottom line is you are doing the responsible thing to care for Bob. Of course, you don't need to tell the vet what you're doing. It's not like she's at home with you!

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Yeah, I'm thinking she's not going to change her mind, but that's ok. I imagine the way she does things has been successful, but I'm just not willing to take a chance with my cat - I certainly won't take the chance he'll go hypo when I'm at work or sleeping so I will continue to test him and continue to increase slowly. I may leave Bob at 3.5 while I transition his food. I have the Young Again and I saw one kitty on the board - Ninja - had very successful results almost immediately. I think he would prefer the YA to the wet foods...

Sienne and Gabby said:

Giving Bob tuna water all by itself is fine. I would just make sure that there's nothing in it except tuna and water -- no onions, garlic, soy, salt, etc. Most cats don't have a huge thirst drive. This is why adding liquid to our cat's food will often insure that they will get additional fluid. If Bob will slurp up tuna water, go for it.

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I'll def give that a try tomorrow. I want to make sure he's getting lots of water.

Sienne and Gabby said:

I would suggest dropping Marje a note. She uses a holistic vet and is more knowledgeable about supplements than I am.

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Thanks for that! I will definitely check with Marje. I would just like to get some info on it. I think I still have some options before I have to resort to acupuncture, but we'll see! Thanks again!